Outside Student 
BLS Refresher Registration Form

NOTE: Find the date you would like to attend on the left, and pick a time to attend that class on the right. Please choose only ONE date and time to attend.

 

Date to Attend Time to Attend
April 3, 2014       
April 8, 2014  
April 30, 2014  
May 8, 2014  
May 16, 2014  
May 30, 2014  
June 4, 2014       
June 24, 2014  
June 30, 2014  
July 7, 2014  
July 18, 2014  
July 31, 2014  
August 7, 2014  
August 15, 2014  
August 29, 2014  
September 3, 2014  
September 11, 2014  
September 30, 2014  
 
 
Last Name
First Name
Middle Initial
Credentials (MD, RN, etc)
Address
City
State
Zip Code
Phone Number
Alternate Phone Number
Employer
E-mail Address
Last Four of Your Social Security Number
Month and Day of Your Birthday (MM/DD)
Fee for Course
                                                                 
Method of Payment
                                                                 
   

If payment will be by check, please mail to:

Department of Life Support Education
Wake Forest Baptist Medical Center
Medical Center Boulevard
Winston-Salem, NC 27157

 If paying in cash, please deliver in person to the Department of Life Support Education-3rd floor South Building.
If paying by credit card, you may pay the day of class unless you are attending a class after 5pm. If attending an after-hours class, please call 336-716-2800 or 336-716-2888 to pay.
   
Comments/Concerns  
We will notify you of your acceptance into the class through the email address you provided.

Quick Reference

Life Support Education
Tiffany Loggins
For BLS, ACLS, & ITLS Questions

Phone 336-716-2800
Fax 336-716-5927

Contact Tiffany
tloggins@wakehealth.edu

Jill Pettit
For PALS, NRP, ENPC, TNCC, PITLS, & E-Learning Questions

Phone 336-716-2888
Fax 336-716-5927

Contact Jill
jpettit@wakehealth.edu

3rd Floor South Building
Find a Doctor Ways to Give
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.